| ARCHETYPE ID | openEHR-EHR-CLUSTER.tnm-pathological_test.v0 |
|---|---|
| Concept | TNM pathological classification |
| Description | A framework for the pathological classification and stage grouping of malignancies using the TNM system. |
| Use | Use to record the pathological classification, designated as pTNM, and stage grouping of malignancies. This archetype has been designed to be nested inside an ENTRY or appropriate CLUSTER archetype which will provide a clinical or pathological context for the TNM record - for example: the 'Specific details' SLOT within the EVALUATION.problem_diagnosis archetype; or nested in an appropriate histopathology-related CLUSTER archetype within the OBSERVATION.laboratory_test_result context. Each cancer has a set of unique pTNM classification values. It is expected that this archetype will be further constrained to reflect the unique requirements for each tumour and edition of the TNM classification, using either an archetype specialisation or a template. With certain types of tumours, such as Hodgkin and other non-Hodgkin lymphomas, a different system for designating the extent of disease and prognosis is used. In these circumstances only the stage group is defined. |
| Misuse | Not to be used to record the TNM clinical classification - use the CLUSTER.tnm archetype for this purpose. |
| Purpose | To record the pathological classification and stage grouping of malignancies using the TNM system. |
| References | Derived from: <Add reference to original resource here> Brierley JD, Gospodarowicz MK, Wittekind C. TNM Classification of Malignant Tumours, 8th Edition. Wiley-Springer; 2016. 272 p. Principles of Cancer Staging. AJCC American Joint Committee on Cancer; [cited 2019 03 15]. Available at: https://facs.groupdropbox.com/share/ac03e57b3ea913ab7d728f5a9f621e84/download?file_ids[]=13911553. TNM Classification Help (Manual for Cancer Staging); [cited 2019 10 04]. Available at: http://cancerstaging.blogspot.com/. |
| Copyright | © openEHR Foundation, Nasjonal IKT HF, openEHR Foundation, openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2016-08-26 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2016-08-26 |
| Other Details (Language Independent) |
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| Keywords | TNM, cancer, tumour, pTNM, grading, staging, malignancy, classification, grouping, stage, neoplasia |
| Lifecycle | in_development |
| UID | cddef4ff-47b0-496e-8626-40d0f99ccec0 |
| Language used | en |
| Citeable Identifier | 1013.1.2138 |
| Revision Number | 0.0.1-alpha |
| Archetype Concept Comment | Designated as pTNM. |
| items | |
| Anatomical site | Anatomical site: The anatomical site where the assessed tumour is situated. For example: stomach; or small intestine. |
| Anatomical subsite | Anatomical subsite: The anatomical subsite where the assessed tumour is situated. For example: cardia, fundus, corpus, antrum and pylorus (stomach); or duodenum, jejunum or ileum (small intestine). |
| Primary tumour (pT) | Primary tumour (pT): Assessment of the primary tumour. Designated as 'pT'. Coding with a T code appropriate for the tumour type and anatomical site is expected. For example: 'pT1'; or 'pT3'. |
| Regional lymph nodes (pN) | Regional lymph nodes (pN): Assessment of the regional lymph nodes. Designated as 'pN'. Coding with an N code appropriate for the tumour type and anatomical site is expected. For example: 'pNX'; or 'pN2'. |
| Distant metastasis (pM) | Distant metastasis (pM): Assessment of distant metastasis. Designated as 'pM'. Coding with an M code appropriate for the tumour type and anatomical site is expected. For example: 'pM1'. |
| Histopathological grade (G) | Histopathological grade (G): Histopathological grading of the tumour. Pretreatment histopathological assessment may be determined from a limited biopsy prior to formal resection. Coding with a G code appropriate for the identified tumour type and anatomical site is expected. For example: 'G2'; 'GX'; or 'low grade' for bone and soft tissue sarcoma classification. |
| Residual tumour (R) | Residual tumour (R): Assessment of the presence of residual tumour after treatment. For example: 'R2 (Macroscopic residual tumour)'.
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| Lymphatic invasion (L) | Lymphatic invasion (L): Assessment of invasion into the lymphatic system. For example: 'L0 (No lymphatic invasion)'.
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| Venous invasion (V) | Venous invasion (V): Assessment of invasion into the venous system. For example: 'V1 (Microscopic venous invasion)'.
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| Perineural invasion (Pn) | Perineural invasion (Pn): Assessment of invasion into the space surrounding nerves. For example: 'Pn0 (No perineural invasion)'.
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| Sentinel node (sn) | Sentinel node (sn): Presence of metastasis within one or more sentinel node(s). Record only if true, designated by addition of the suffix 'sn'. For example: 'pN0(sn) No sentinel lymph node metastasis' or 'pN1(sn) Sentinel lymph node metastasis'. Allowed values: {true} |
| Micrometastases (mi) | Micrometastases (mi): Presence of micrometastases in the regional lymph drainage area of the primary tumour. Record only if true, designated by addition of the suffix 'mi'. For example: 'pN1(mi)'. Allowed values: {true} |
| Regional lymph node ITC | Regional lymph node ITC: Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry in regional lymph nodes. For example 'pN0(i-) No regional lymph node metastasis histologically, negative morphological findings for ITC'; 'pN0(mol+) No regional lymph node metastasis histologically, positive non morphological findings for ITC'; or 'pN0(i+)(sn) No sentinel lymph node metastasis histologically, positive morphological findings for ITC'.
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| Distant metastasis ITC | Distant metastasis ITC: Presence of isolated tumour cells (ITC) detected by H&E stains or immunohistochemistry as distant metastases, such as bone marrow. For example: 'pM0(i+)' or 'pM0(mol+)'.
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| Multiple primary tumours (m) | Multiple primary tumours (m): Presence of multiple simultaneous primary tumours at a single site. Designated as a suffix, either as the letter 'm' or the number of primary tumours. For example: 'pT2(m)' or 'pT2(4)'. Choice of:
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| Multimodality therapy (y) | Multimodality therapy (y): Assessment is performed during or following initial multimodality therapy. Record as true, designated by addition of the prefix 'y'. For example: 'yTNM'. Allowed values: {true} |
| Recurrent (r) | Recurrent (r): Assessment is performed for a recurring cancer after a disease-free interval. Record as true, designated by addition of the prefix 'r'. Allowed values: {true} |
| Autopsy (a) | Autopsy (a): Assessment is performed at postmortem examination. Record as true, designated by addition of the prefix 'a'. Allowed values: {true} |
| Carcinoma in situ (is) | Carcinoma in situ (is): Presence of carcinoma in situ associated with the primary tumour. Record as true, designated by addition of the suffix 'is'. For example: 'pT3(m, is)' or 'pT2(3, is)' or 'pT2(is)'. Allowed values: {true} |
| pTNM assessment | pTNM assessment: Concatenation of 'pT', 'pN' and 'pM' assessments plus any optional assessments of 'G', 'R', 'L', 'V', prefixes and/or suffixes, as applicable. |
| Stage grouping | Stage grouping: The categorisation of the anatomical stage of the tumour, usually based on pTNM assessment. For example: carcinoma in situ is categorised as stage 0; or tumours with distant metastasis are categorised as stage IV. |
| TNM Edition | TNM Edition: The edition of the TNM classification system used for the assessment. |
| Other contributors | Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Hildegard Franke, freshEHR Clinical Informatics Ltd. UK Sergey Kovalenko, Chelyabinsk Regional Children Hospital, Russia Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway (openEHR Editor) Miha Lenic, Marand, Slovenia Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics Ltd. UK SARA PRETE, Abinsula, Italy Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Nasjonal IKT HF, Norway John Tore Valand, Helse Bergen, Norway (openEHR Editor) |
| Translators |
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